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First-Tier, Downstream and Related Entity (FDR) Medicare Compliance Program Guidelines Attestation

FDRs Defined

This Certification of Compliance is for the following First-Tier, Downstream or Related ("FDR") individuals or entities:

A First Tier Entity is any party that enters into a written arrangement, acceptable to CMS, with a Medicare Advantage Organization or Part D plan sponsor or applicant to provide administrative services or healthcare services to a Medicare eligible individual under the Medicare Advantage program or Part D program. (See, 42 C.F.R. §§ 422.500 & 423.501)

A Downstream Entity is any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the Medicare Advantage benefit or Part D benefit, below the level of the arrangement between a Medicare Advantage Organization or applicant or a Part D plan sponsor or applicant and a first-tier entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services. (See, 42 C.F.R. §§ 422.500 & 423.501)

A Related Entity means any entity that is related to an MA organization or Part D sponsor by common ownership or control and: 1) Performs some of the MA organization or Part D plan sponsor's management functions under contract or delegation; 2) Furnishes services to Medicare enrollees under an oral or written agreement; 3) Leases real property or sells materials to the MA organization or Part D plan sponsor at a cost of more than $2,500 during a contract period (See 42 CFR §§ 422.500 and 423.501.)

Individual FDRs (e.g., independent physicians/pharmacists) and authorized representatives of FDR entities (e.g., management staff of physician groups and Pharmacy Benefit Manager [PBM]) must complete an attestation.

For purposes of this attestation, "CommunityCare's Medicare products" includes CommunityCare's Medicare Advantage (MA), Prescription Drug Plans (PDP and MAPD), and/or Medicare-Medicaid Plan (MMP) product lines under contract with CMS. Within the attestation, the terms "employee" and "Downstream Entity" refer only to those supporting CommunityCare's Medicare products.

Compliance Requirements

This attestation confirms your commitment to comply with the Centers for Medicare & Medicaid Services (“CMS”) requirements. CMS's guidance for Medicare Advantage organizations and Part D sponsors are published in both, Pub. 100-18, Medicare Prescription Drug Benefit Manual, Chapter 9 and in Pub.100-16, Medicare Managed Care Manual, Chapter 21, and are identical in each. You must submit the attestation by December 31st in order to be in compliance with CMS requirements. A brief description of the requirements that your organization and/or you are attesting to are as follows:

1. Code of Conduct ("COC") and/or Compliance Policies

My organization has adopted either CommunityCare's or a comparable COC and/or Compliance Program policies which were distributed to applicable employees within 90 days of hire, upon revision, and annually thereafter.

2. Fraud, Waste and Abuse (''FWA") and General Compliance Training

By completing this attestation, I am confirming that my organization ensures that Medicare Parts C and D General Compliance and Fraud, Waste, And Abuse required training/education is completed within 90 days of initial hire or the effective date of contracting, when materials are updated, and annually thereafter.

3. Office of Inspector General (OIG) and General Services Administration's System for Award Management (SAM) exclusion screening

My organization screens the US Department of Health & Human Services Office of Inspector General (OIG) and the General Services Administration's System for Award Management (SAM) exclusion lists, the CMS Provider Opt-Out list and the CMS Preclusion list prior to hire or contracting, and monthly thereafter, for applicable employees and Downstream Entities. My organization removes any person/entity from work on CommunityCare Medicare products if found on these lists.

4. Reporting Mechanisms

My organization has communicated to applicable employees how to report suspected or detected non-compliance or potential FWA, and that it is their obligation to report without fear of retaliation or intimidation against anyone who reports in good faith. My organization either requests applicable employees report concerns directly to CommunityCare or maintains confidential and anonymous mechanisms for applicable employees to report internally. In turn, we report these concerns to CommunityCare, when applicable.

5. Offshore Operations

For any work my organization performs that involves the receipt, processing, transferring, handling, storing or accessing of Protected Health Information ("PHI"), my organization either doesn't do the work offshore, doesn't have Downstream Entities that do the work offshore, or does the work offshore (ourselves or through a Downstream Entity) but has submitted CommunityCare's Offshore Services Attestation: Required Information form and obtained approval from an authorized CommunityCare representative to do so.

6. Downstream Entity Oversight

My organization either doesn't use Downstream Entities or uses Downstream Entities for CommunityCare Medicare products and conducts robust oversight to ensure that they comply with all the requirements described in this attestation (e.g., FWA training, OIG and GSA's SAM exclusion screening, etc.) and any applicable laws, rules and regulations.

7. Operational Oversight

My organization conducts internal oversight of the services that we perform for CommunityCare Medicare products to ensure that compliance is maintained with applicable laws, rules, and regulations.

Attestation Statement

I certify, as an authorized representative of my organization, that the statements made above are true and correct to the best of my knowledge. Also, my organization agrees to maintain documentation supporting the statements made above. My organization will maintain this documentation in accordance with federal regulations for a period no less than ten (10) years. My organization will produce this evidence, upon request. My organization understands that the inability to produce this evidence may result in a request for a Corrective Action Plan (CAP) or other contractual remedies such as contract termination.

 
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